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BackgroundCareful design of preprinted order sets is needed to prevent medical overuse. Recent work suggests that removing a single checkbox from an order set changes physicians’ clinical decision-making.Local problemDuring a 2-month period, our coronary care unit (CCU) ordered almost eight times as many serum thyroid-stimulating hormone (TSH) tests as our neighbouring intensive care unit, many without a reasonable clinical basis. We postulated that we could reduce inappropriate testing and improve clinical laboratory stewardship by removing the TSH checkbox from the CCU admission order set.MethodsAfter we retrospectively evaluated CCU TSH ordering before intervention, the checkbox was removed from the CCU admission order set. Twelve weeks later, we commenced a prospective 2-month assessment of TSH testing and clinical sequelae of thyroid disease among all CCU admissions. If clinical indications were absent or testing had occurred within 6 weeks, TSH requests were labelled as ‘inappropriate’.ResultsPhysician ordering and, specifically, inappropriate ordering decreased substantially after the intervention. In 2016 among physician-ordered TSH tests, 60.6% (66/109) were inappropriate; in 2017 this decreased to 20% (2/10, p=0.01). Overall, the net effect of checkbox removal saw the decrease in TSH testing without clinical indication outweigh an increase in missed testing where indications appear to exist.ConclusionsProvision of an optional checkbox for a laboratory test in an admission order set can promote overuse of laboratory resources. Simple removal of a checkbox may dramatically change test ordering patterns and promote clinical laboratory stewardship. Given our reliance on order sets, particularly by trainees, changes to order sets must be cautious to assure guideline-directed care is maintained.

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GSR Philteos, K Coverett, R Chibbar, HA Ward, DW Cockcroft. Asbestosis and probable microscopic polyangiitis. Can Respir J 2004;11(5):359-362.Several inorganic dust lung diseases (pneumoconioses) are associated with autoimmune diseases. Although autoimmune serological abnormalities are common in asbestosis, clinical autoimmune/collagen vascular diseases are not commonly reported. A case of pulmonary asbestosis complicated by perinuclear-antineutrophil cytoplasmic antibody (myeloperoxidase) positive probable microscopic polyangiitis (glomerulonephritis, pericarditis, alveolitis, multineuritis multiplex) is described and the possible immunological mechanisms whereby asbestosis fibres might be relevant in induction of antineutrophil cytoplasmic antibodies are reviewed in the present report.Key Words: Primary care; Screening; Spirometry Amiantose et polyangéite microscopique probablePlusieurs pneumopathies (pneumoconioses) liées aux poussières inorganiques sont associées à des maladies auto-immunes. Même si les anomalies sérologiques auto-immunes sont fréquentes dans l'amiantose, la documentation fait rarement état de maladies auto-immunes ou de collagénose avec manifestations cardiovasculaires décelables cliniquement. Voici un cas d'amiantose pulmonaire, compliquée d'une polyangéite (glomérulonéphrite, péricardite, alvéolite, polynévrite) microscopique probable à anticorps cytoplasmiques antineutrophiles périnucléaires (myéloperoxydase). Il sera également question de mécanismes immunitaires possibles mis en cause dans le rôle des fibres d'amiante dans l'induction des anticorps cytoplasmiques antineutrophiles.